When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Apply a warm compress to the sacral area.

Wash the area with soap and water.

Reassess and turn the client in 30 minutes.

Massage the reddened area with lotion.

Answer and Explanation

The Correct Answer is C

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

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Correct Answer is C

Explanation

A. While it is important to address unprofessional behavior, directly warning the colleague may not be sufficient to address the breach of security protocols effectively.
B. Discussing the action at a staff meeting may not address the immediate issue and could lead to general discussions rather than specific corrective actions.
C. Communicating the observation to the charge nurse is appropriate because it ensures that the issue is reported to a person who can take immediate action to address the breach of EHR security and prevent further unauthorized access.
D. Filing a detailed incident report may be necessary, but first, informing the charge nurse is crucial for immediate action and to address the issue promptly. The charge nurse can then guide the next steps, including filing a report if necessary.

A. "This must be a very difficult time for you." B. "You did nothing wrong." C. "With surgery, your baby should have a full recovery." D. "Is there any particular reason why you think this is your fault?"

Correct Answer is A

Explanation

A. Acknowledging that this is a difficult time for the mother is empathetic and supportive. It provides an opportunity for the mother to express her feelings and concerns without placing blame, which can be helpful in managing emotional distress.
B. While reassuring the mother that she did nothing wrong is important, it does not fully address her emotional needs or allow her to express her feelings. It may be perceived as dismissive if not accompanied by empathy.
C. Reassuring the mother about the outcome of surgery is important, but it does not address the emotional impact of her feelings of guilt or responsibility.
D. Asking why the mother thinks it is her fault may not be as supportive or helpful as providing empathy and reassurance. It could potentially lead to further distress rather than addressing the emotional support she needs.

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When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?

Correct Answer is C

Explanation

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Correct Answer is A

Explanation

The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?

The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?